2.0 Analysis 2.1 Introduction The causes of the near-collision of the tanker DIAMOND STAR with a pier of the Laviolette bridge were analyzed in the light of the facts reported and the statements of the persons involved in the occurrence. The reports concerning the health of the pilot were obtained from the attending physicians and from health care facilities in accordance with the Canadian Transportation Accident Investigation and Safety Board Act. 2.2 Night Vision When the pilot came aboard the vessel in the port of Trois-Rivires, he proceeded directly to the wheel-house via a lighted stairway. Only a few minutes elapsed between the pilot's taking the conduct of the vessel and the time the near-collision occurred. This period perhaps was not long enough to allow the pilot's eyes to adapt fully to the ambient light conditions. 2.3 Lighting on Screens and Indicators Examination of the brightness of the radar screens and indicators in the wheel-house revealed that the lighting on these instruments can be adjusted to facilitate reading at all times. This lighting does not affect the vision of the bridge personnel, and exterior details can be seen normally after using the instruments. Examination of the area revealed no other light sources that could interfere with the work of the bridge personnel. It is unlikely that the ergonomic characteristics of the bridge and bridge equipment, in particular the ARPA radar screen, contributed to the occurrence. 2.4 Bridge Resource Management (BRM) When the pilot came aboard, he met briefly with the master, but little information was exchanged; it is not unusual for a vessel to change pilots in this manner. During their brief encounter, the master did not have enough time to detect anything unusual about the pilot's behaviour. More effective BRM making better use of the resources available, such as equipment and communications, may have prompted the pilot to report that he could not locate the piers of the bridge and to ask the bridge personnel for assistance in locating them. He did not inform the ship's officers of his difficulties in identifying the channel, and the master had to intervene at the very last moment. 2.5 Laviolette Bridge The Laviolette bridge is easily locatable at night because of the street lamps illuminating it. However, there have been several reports that the brightness level of the navigation lights marking the channel is low. Some persons apparently have difficulty determining the position of the bridge piers using these lights, even in conditions of good visibility. Since the bridge piers have been protected by rock berms, it is risky for a vessel the size of the DIAMOND STAR to pass under the Laviolette bridge between the first two piers to the north of the centre channel. The pilot stated that, at the last minute, he had decided to steer through that channel. Given the critical situation, this was not without hazards. The risk of accident was even greater because the master was not aware of the pilot's intention and the situation was unclear. 2.6 Pilot's Health The master of the DIAMOND STAR maintained that the pilot's reactions were not normal, that he was either under the influence of alcohol or drugs, or incompetent. Because the pilot did not undergo tests to determine if his ability was actually impaired by drugs or alcohol at the time of the occurrence, this question cannot be resolved. The pilot's medical history indicated that he had been suffering from chronic alcoholism for many years. He had signed up a few times for alcoholism treatment programs offered by health care facilities. It is well known that alcohol abuse over a prolonged period can have long-term effects on a person. These effects can cause functional disorders, whether physical or mental, that sometimes affect an individual's performance.(4) 2.7 Assistance Program for Pilots Because the acts and regulations governing pilots do not make provisions to assist pilots who need professional treatment for alcohol or drug abuse, pilots have only two options: undergoing treatment during off-duty periods without informing the pilotage authority or corporation to avoid risking suspension of their licence; or requesting assistance from the pilotage authority or corporation without knowing whether they will be helped or have their licence suspended. Both options involve financial and personal risks for the pilot and offer no incentive to participate in a rehabilitation program. 3.0 Conclusions 3.1 Findings At the time of the occurrence, the pilot had been on board the DIAMOND STAR for only a few minutes. The unlighted spar buoys marking the channel at the Laviolette bridge were in their charted positions and the racons marking the north and south sides were working properly. It has been reported that the brightness level of the navigation lights located under the bridge span is low. Little information was exchanged between the pilot and crew. The pilot did not ask the bridge personnel for assistance in locating the bridge piers. The pilot had a severe alcohol addiction problem. There was no program for the prevention and diagnosis of alcohol and/or drug addiction for marine pilots. Pilots are required to have a medical examination at least once every three years. The Laurentian Pilotage Authority (LPA) took no steps to follow up on the pilot's report and to check on his continued abstinence, nor to encourage him to continue with rehabilitation. The ergonomic characteristics of the bridge apparently did not contribute to the occurrence. 3.2 Causes The pilot's health and state of mind when he took the conduct of the DIAMOND STAR very likely led to the near-collision. Contributing factors to this occurrence were the adaptation of the eyes to darkness and the low brightness level of the navigation lights on the bridge. 4.0 Safety Action 4.1 Action Taken 4.1.1 Audit of Medical Reports Following this occurrence, the pilot, whose licence was suspended for four months, underwent detoxification treatment. Thereafter, the Laurentian Pilotage Authority (LPA) proceeded to test the pilot at random for drug and alcohol use. The pilot agreed to these tests which were a condition to the suspension of his licence being lifted. In the weeks following this occurrence, the pilotage authority contacted appointed medical doctors to make them aware of the importance of submitting medical reports written legibly and in layman's terms. The pilotage authority also changed its internal procedure for auditing medical reports in order to detect any potential problem. 4.1.2 Medical Fitness for Duty In its report on the collision between the Canadian Coast Guard Ship GRIFFON and the fishing vessel CAPTAIN K which occurred in Long Point Bay, Lake Erie, on 18 March 1991 (TSB Report No. M91C2004), the Board recommended that: The Department of Transport, in cooperation with Health Canada and the Canadian Coast Guard, define policies and procedures to ensure that personnel returning to safety-sensitive duties following any medical treatment are fit for those duties. (M95-05, issued July 1995) In response to this recommendation, Transport Canada, Health Canada and the Canadian Coast Guard held meetings with groups of employers and employees of the commercial shipping industry. The consensus which came out of these meetings was that the anticipated results will be achieved through the recently modified Crewing Regulations. If there is any doubt as to an employee's physical and/or mental fitness for duty, Transport Canada and the shipowners will have the authority to require that employee to undergo another medical exam before returning to work. 4.1.3 Lighting of the Laviolette Bridge Piers Following this occurrence and at the request of ship's pilots, Transports Qubec has fitted additional lights under the bridge to illuminate the first two piers on each side of the centre channel.